POSITRON EMISSION TOMOGRAPHY (PET) OF THE BRAIN. DOES IT HELP IN BRAIN INJURY REHABILITATION?
Bjorn H Johansson, A R Fugl-Meyer, C Tengvar, (Department of Rehabilitation Medicine, Uppsala University, Uppsala, Sweden)
Purpose: Brain-imaging using static descriptions of brain anatomy such as computerized tomography (CT) and magnetic resonance imaging (MRI) is widely used when diagnosing the focality or globality of a brain damage. It is, though, believed that dynamic imaging methods may be of considerable assistance both concerning the differential diagnosis in brain injury - for instance to differ between vegetative and locked-in states and in choosing individualized stimulation approaches within rehabilitation medicine. Several dynamic imaging techniques, such as dynamic MRI, digitalized EEG and PET or SPECT are at the moment available but very rarely systematically used. Cortical evoked potentials in response to periferal stimuli are on the other hand somewhat more commonly used; but are rarely conclusive.
Subjects and methods: A series of patients with brain damage, - in the majority a traumatic one - were investigated one or, in some cases, two times using PET and registering either the global brain blood flow or the brain (glucose) metabolism.
Results: In all cases the PET verified the CT or MRI diagnosed focal lesion(s). Most subjects, however, had pathologically low blood flow/glucose metabolism in other - sometimes distant - areas of the brain.
Conclusions: From this empirical investigation, which to some extent resembles those clone by others, particularly Japanese, authors, we can conclude that after traumatic and even subarachnoid haemorrhagic brain damage multifocal lesions appear to be the rule. This multifocality may be due to primary diffuse axonal injuries (DAI), multifocal primary lesions, secondary lesions due to altered intrathecal pressure /metabolism or - particularly concerning the thalamus - due to secondary adaptation to decreased neuronal transmissions. At the moment, we have found that PET may be of differential diagnostic value, but it appears that we have a long way to go before PET has direct clinical implications.
THE DEVELOPMENT OF AN IMPROVED RETURN TO WORK PROCESS FOR TRAUMATIC BRAIN INJURY PATIENTS
John P. Marchin, M.D.; Margaret Sak, O.T.R.; Judy Hawkins, O.T.R.; Barbara Walsh, M.S. (Memorial Hospital of South Bend, Indiana, U.S.A.)
Patients with traumatic brain injury represent a challenge related to returning them successfully back to work because of residual physical and cognitive problems. Traditionally this is a very complex process which requires extensive coordination and communication among the patient, family, various healthcare professionals, employers, payors, and other agencies' staff. The purpose of our study was to analyze the return to work process for these patients utilizing a multifaceted approach. Our methodology was a process improvement procedure which enhanced an existing work process in the outpatient rehabilitation center. A core design team consisting of a physiatrist, an outpatient rehabilitation manager, a facilitator, and other consultants met regularly to refine this clinical work process. The results of our assessment lead to the development of a detailed clinical path diagram which facilitated a more coordinated clinical process. From this analysis, we were able to do problem solving and more effectively communicate either returning the patient to work or facilitating plans for the patient to accept a new lifestyle should they be unable to return to work. Our conclusion is that by utilizing process improvement techniques we developed an enhanced program to assess traumatic brain injury patients capacity to return to work.